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Abnormal vaginal discharge and male urethral discharge

Sexual health update

In this new series, Dr Neil Lazaro advises on how to identify and manage STIs through presenting symptoms

Abnormal vaginal discharge

Background

This article concerns women of reproductive years (beware vaginal discharge in the post-menopausal woman, which could indicate cancer). Some women may simply be noticing physiological discharge, so it is always important to take a careful history.

With abnormal vaginal discharge, it is estimated that:

•one-third of cases are candida

•one-third of cases are bacterial vaginosis

•one-third of cases are STIs or physiological

History

See table 1 on page 29 for clues to diagnosis.

•What is the consistency? Is it itchy, malodorous, cyclical?

•If it sounds physiological, reassure but

examine if necessary.

•If is sounds like candida, pragmatically, consider giving treatment straight away if you think this is the likely diagnosis, but review and examine if symptoms persist. Is it recurrent candida? Recurrent herpes? Lichen sclerosus?

•Is it bloodstained?

•Is there abdominal pain/fever/deep dyspareunia/irregular bleeding?

•Is the patient post menopausal?

•Are there other symptoms or is the diagnosis unclear?

•Is there malodour and/or is the discharge recurrent?

For recurrent malodorous discharge that has previously been diagnosed as bacterial vaginosis and is recognised by the patient as being an uncomplicated recurrence, consider simply giving prescription rather than examining. This is pragmatic management and must be assessed on an individual clinical basis.

Examination

See tables on page 29 for clues to diagnosis and the algorithm for a management plan.

•Appearance of discharge

•Evidence of cervicitis? Take endocervical swabs for chlamydia and gonorrhoea, as well as an HVS

•Retained foreign body? Remove and consider metronidazole if malodour; however, this isn't always needed once the foreign body is removed

•Do PV if abdominal pain (treat early if you suspect PID)

Investigations

pH

•Normal vaginal pH is up to 4.5 (kept acidic by friendly lactobacilli).

•It's an indicator of vaginal ecology, but is not very specific.

•It can be raised with local blood, semen and cervical secretions.

•Raised pH can give you clues about BV and TV (altered ecology).

•Raised pH can also indicate chlamydia or gonorrhoea, so if raised, check for these too (endocervical swabs, not an HVS).

•To measure vaginal pH, take a swab, rub it along the lateral wall collecting some discharge, then rub it onto pH paper.

High vaginal swabs

•High vaginal swabs (HVSs) are much used by GPs – but there is poor evidence of their being useful.

•Not always used in GUM clinics – partly because their usefulness is questionable, and partly because GUM clinics are able to do near-patient tests such as microscopy (which can give 'instant' results for BV, TV and candida) so easily.

•May be useful to find micro-organisms that can cause cervicitis/endometritis/salpingitis, so consider taking an HVS in these circumstances, although the most important tests will be endocervical swabs for chlamydia and gonorrhoea.

Why is the usefulness questionable?

•There is some evidence the information provided by the lab from an HVS isn't exactly what the GP thought it would be2.

•Labs may differ in what tests they do and what organisms they report, and also what advice on prescriptions/treatment they may give.

•Some labs will run more tests than others; some will run more tests when detailed

clinical information is given. You should discuss these points with your lab.

•Some evidence3 that the diagnostic yield of an HVS is poor except for finding candida, which produces characteristic symptoms anyway (and if it's not producing symptoms you wouldn't need to treat).

•Some evidence that the HVS is of limited value in diagnosing BV (and may lead to underdiagnosis if no other diagnostic criteria are used)4.

So, should GPs take HVSs?

•Probably useful to confirm organisms that can cause or complicate cervicitis/endometritis/salpingitis, so take an HVS if you suspect these conditions.

•May also be useful in persistent vaginitis, for group B strep screening and in post-

partum and post-instrumentation infections. It is also of use when trying to prove a diagnosis of recurrent candidiasis.

•Think about why you are taking the swab. If it's for STIs, then take endocervical swabs for chlamydia and gonorrhoea.

•Do not rely on an HVS to diagnose TV – send the patient to the GUM clinic.

•If you do send a swab, give the lab as much clinical information as possible. Do not assume that a full range of tests will be run on your sample. Talk to your lab.

•Do not diagnose BV just because

Gardnerella vaginalis is found on an HVS – it is found in 30 to 40 per cent of 'normal' women.

Other tests

Consider taking air-dried slides:

•Smear a thin layer of discharge on a

microscope slide, then allow to air dry and send to lab for gram staining (the lab can look for signs of infections on microscopy). Please discuss with your own lab first about doing this.

Male urethral

discharge

Background

(Based on information from reference 1)

Urethral discharge is a result of urethritis, which is usually due to a sexually transmitted infection.

Urethritis can produce the following symptoms (not all may be present):

•Urethral discharge (ranges from mildly mucoid to highly purulent)

•Urethral 'itch'/discomfort

•Dysuria – don't assume dysuria in a male is always a UTI. A sexually active man with dysuria must have STIs excluded.

The cause may be infection (you cannot reliably distinguish these clinically):

•Chlamydia

•Gonorrhoea (also known as 'gonococcus' or 'GC' for short)

•NSU – this is really a diagnosis of exclusion after GC and chlamydia have been ruled out – lots of different organisms can cause this, such as ureaplasma, mycoplasma, TV, yeasts, herpes and anaerobic balanitis.

Management

•Refer to GUM clinic

or

•If an urgent (< 48="" hours)="" appointment="" is="" not="" possible="" then="">

– taking tests for STIs (ideally after

patient has held urine > four hours)

– and then treating empirically (see

below)

Notes:

•This is not ideal but is simply pragmatic especially if it is a Friday evening of a long bank holiday weekend when urgent GU

access may be difficult.

•Treating an STI promptly not only alleviates symptoms but also halts the subsequent spread of infection.

•If you decide to treat a presumed STI, you must attend to the process of notifying recent sexual partners, who may be unaware they might be carrying an asymptomatic infection. At the very least, this involves telling the index patient they should abstain from sex until recent sexual partners have been checked and treated if necessary, and that those partners should seek medical advice. Watertight partner notification is difficult to achieve in general practice and is probably best left to GUM clinics.

Tests

You should talk to your local lab or clinic about which swabs to use.

•Urethral swabs for GC (charcoal swab) and chlamydia swab or first pass urine (NAAT test)

•Consider a first pass urine – to look for 'threads'. These are strands of mucus/pus suspended in urine. They can be a useful clue for urethral inflammation, but this is not very sensitive or specific and should not be relied upon as a sole diagnostic criteria for urethritis.

Treatment

•The treatment for chlamydia and NSU is:

Azithromycin 1g po stat

or

Doxycycline 100 mg po bd 7/7

•The treatment for uncomplicated urethral gonorrhoea is currently (this may change):

Cefixime 400 mg po stat

So...

•Very purulent discharge? Err on side of caution and suspect GC, (especially if recent SI abroad).

Treat for both GC and chlamydia/NSU just in case (this may well be overtreatment, but is pragmatic in a GP setting)

Treatment: Cefixime 400 mg po

stat plus

Doxycycline 100 mg po bd 7/7 or Azithromycin 1g po stat

•Mild symptoms? Suspect chlamydia or NSU and await GC swab result

Treatment: Doxycycline 100 mg po bd 7/7

or

Azithromycin 1g po stat

Notes:

•Advise patient to tell partner(s) to attend GUM clinic (or see GP) for treatment. Consider giving the patient handwritten notes with date of diagnosis and prescription given. The index patient may then give this to contacts to hand to their doctor.

•Consider follow-up in two weeks (to check for treatment compliance, partner notification, symptoms resolution, etc)

•Advise patient to have no sexual encounters at all until given all clear (not even with a condom, as we know that carelessness can occur before a condom is put on, and this may be enough to transfer infectious agents – and condoms can also split). 'No sex' includes all genital-mucous membrane contact (so no oral sex either).

•They may not attend for follow-up, so when you treat them initially, advise no sex until seven days after treatment finishes, symptoms are resolved and the partner is successfully treated. Document this.

Partner notification 2

How far back you trace depends on what the diagnosis is and when the man developed urethral symptoms.

•Gonorrhoea

– symptoms? All sexual partners in previous two weeks

– no symptoms? All sexual partners in previous three months

•Chlamydia

– symptoms? All sexual partners in previous four weeks

– no symptoms? All sexual partners in previous six months

•NSU (ie urethritis that was neither chlamydia nor gonorrhoea)

– symptoms? All sexual partners in previous four weeks

– no symptoms? All sexual partners in previous six months

These figures are arbitrary as it is not known for sure how long asymptomatic

carriage can be. Common sense should be used in assessing which sexual partners may have been at risk, and sometimes longer time periods may be involved. Talk to your local clinic if concerned.

Ideally, partner notification should be pursued in all patients, preferably by a trained health advisor in GU medicine, who can also document action and outcomes. This applies, to a greater or lesser degree, to all STIs. For the time being, watertight partner notification remains difficult to achieve in primary care. You should at least be aware of the need for it and document that you have discussed this with the patient.

This article is based on Sexually Transmitted Infections in Primary Care by Dr Neil Lazaro, published by the RCGP sex, drugs and HIV task group and the British Association for Sexual Health and HIV. See www.rcgp.org.uk/default.aspx?page=4338

Acknowledgements to Professor Cathy Ison for advice on the section on abnormal vaginal discharge.

Neil Lazaro is a GP hospital practitioner in GU medicine in Lancaster, a member of the RCGP sex, drugs and HIV task group and he also sits on the BASHH clinical effectiveness group.

References

1 Sobel J. Vaginitis. N Eng J Med 1997;337:1896-903

2 Noble et al. How is the high vaginal swab used to investigate vaginal discharge in primary care and how do GPs' expectations of the test match the tests performed by their microbiology services? Sex Transm Infect 2004;80:204-6

3 Jungmann et al. How useful are high vaginal swabs in general practice? Results of a multicentre study. Int J STD&AIDS 2004;15:238-9

4 Crowley et al. Can a laboratory diagnosis of bacterial vaginosis be made from a transported high vaginal swab using anaerobic culture and microscopy of a wet preparation? Sex Transm Infect 1998;74: 228

5 Holmes et al. Sexually Transmitted Infections. McGraw-Hill 1999

6 Clinical Effectiveness Group. UK National Guidelines on Sexually Transmitted Infections and closely related conditions. British Association for Sexual Health and HIV. www.bashh.org/guidelines

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